MAUDE Adverse Event Report: CAREFUSION ALARIS PUMP MODULE ADMINISTRATION SET; SET, ADMINISTRATION, INFUSION

Model Number 2420-0007

Device Problems False Alarm (1013); Stretched (1601); Obstruction of Flow (2423)

Patient Problem No Consequences Or Impact To Patient (2199)

Event Date 11/18/2019

Event Type  malfunction  

Manufacturer Narrative

Although requested, product has not been received.A follow up report will be submitted with failure investigation results should the product be received for evaluation.Although requested, patient demographics were not provided.

Event Description

It was reported that during mid infusion, they were doing a syringe push to the patient and had an alarm.There was no patient harm.

Manufacturer Narrative

Additional information added; h.6.(device code) no product will be returned per customer.The customer¿s report of syringe push to the patient and an alarm and causing a balloon in the silicone segment was confirmed per photo provided by the customer.Photo provided shows a bulge/balloon in the silicone segment tubing near the upper fitment.The root cause for the source of the excessive pressure is unknown.

Event Description

It was reported that during a mid-infusion, they were doing a syringe push to the patient and had an alarm.Picture provided by the customer shows a "bulging" in the silicone segment.It was further confirmed during follow up, that there was no patient harm as a result of this event.

• Brand Name: ALARIS PUMP MODULE ADMINISTRATION SET
• Type of Device: SET, ADMINISTRATION, INFUSION
• Manufacturer (Section D): CAREFUSION; 10020 pacific mesa blvd; san diego CA 92121 4386
• MDR Report Key: 9511962
• MDR Text Key: 191110286
• Report Number: 9616066-2019-03674
• Device Sequence Number: 1
• Product Code: FPA
• UDI-Device Identifier: 07613203021012
• UDI-Public: 7613203021012
• Combination Product (y/n): N
• PMA/PMN Number: K944320
• Number of Events Reported: 1
• Summary Report (Y/N): N
• Report Source: Manufacturer
• Source Type: company representative,health
• Type of Report: Initial,Followup
• Report Date: 12/02/2019

1 Device was Involved in the Event

1 Patient was Involved in the Event

• Date FDA Received: 12/23/2019
• Is this an Adverse Event Report?: No
• Is this a Product Problem Report?: Yes
• Device Operator: Health Professional
• Device Model Number: 2420-0007
• Device Catalogue Number: 2420-0007
• Was Device Available for Evaluation?: No
• Is This a Reprocessed and Reused Single-Use Device?: No
• Patient Sequence Number: 1